1902262272 NPI number — BRADSHAW MOUNTAIN FAMILY MEDICINE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902262272 NPI number — BRADSHAW MOUNTAIN FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADSHAW MOUNTAIN FAMILY MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902262272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2030 W BASELINE RD STE 182-549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85041-6574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-683-1170
Provider Business Mailing Address Fax Number:
833-675-0005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1163 E OLD CHISHOLM TRAIL SUITE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEWEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-710-1971
Provider Business Practice Location Address Fax Number:
844-250-8735
Provider Enumeration Date:
01/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-542-9906

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN145916 AP7984 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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